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General NPI Number Information
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NPI Number | 1790162980
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Entity Type | Organization
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Legal Business Name | PANIOLO PEDIATRICS LLC
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Dates
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Enumeration Date | 04/27/2015
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Last Update Date | 04/27/2015
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Provider Practice Location Address
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Address Line | 64-1032 MAMALAHOA HWY STE 204
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City | KAMUELA
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State | HI
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Zip | 96743-8441
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Country | US
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Telephone | 808-887-6543
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Fax | 808-887-6294
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Provider Business Mailing Address
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Address Line | PO BOX 6149
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City | KAMUELA
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State | HI
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Zip | 96743-6149
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Country | US
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Telephone | 808-887-6543
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Fax |
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Authorized Official
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Title or Position | SOLE MEMBER
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Name | DR. BRETT COLIN FERGUSON
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Credential | MD
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Telephone | 808-887-6543
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | MD16732
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License Number State | HI
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